Schistosome-induced cholangiocyte proliferation and osteopontin secretion correlate with fibrosis and portal hypertension in human and murine schistosomiasis mansoni.

Schistosomiasis is a major cause of portal hypertension worldwide. It associates with portal fibrosis that develops during chronic infection. The mechanisms by which the pathogen evokes these host responses remain unclear. We evaluated the hypothesis that schistosome eggs release factors that directly stimulate liver cells to produce osteopontin (OPN), a pro-fibrogenic protein that stimulates hepatic stellate cells to become myofibroblasts. We also investigated the utility of OPN as a biomarker of fibrosis and/or severity of portal hypertension. Cultured cholangiocytes, Kupffer cells and hepatic stellate cells were treated with soluble egg antigen (SEA); OPN production was quantified by quantitative reverse transcriptase polymerase chain reaction (qRTPCR) and ELISA; cell proliferation was assessed by BrdU (5-bromo-2'-deoxyuridine). Mice were infected with Schistosoma mansoni for 6 or 16 weeks to cause early or advanced fibrosis. Liver OPN was evaluated by qRTPCR and immunohistochemistry (IHC) and correlated with liver fibrosis and serum OPN. Livers from patients with schistosomiasis mansoni (early fibrosis n=15; advanced fibrosis n=72) or healthy adults (n=22) were immunostained for OPN and fibrosis markers. Results were correlated with plasma OPN levels and splenic vein pressures. SEA-induced cholangiocyte proliferation and OPN secretion (P<0.001 compared with controls). Cholangiocytes were OPN (+) in Schistosoma-infected mice and humans. Liver and serum OPN levels correlated with fibrosis stage (mice: r=0.861; human r=0.672, P=0.0001) and myofibroblast accumulation (mice: r=0.800; human: r=0.761, P=0.0001). Numbers of OPN (+) bile ductules strongly correlated with splenic vein pressure (r=0.778; P=0.001). S. mansoni egg antigens stimulate cholangiocyte proliferation and OPN secretion. OPN levels in liver and blood correlate with fibrosis stage and portal hypertension severity.

Angiogenesis and schistosomiasis.

Angiogenesis has been recognised as a precursor of fibrosis in several pathologic conditions. Its participation has been demonstrated in schistosomiasis, both during periovular granuloma formation and in the genesis of schistosomal periportal fibrosis. Paradoxically, proliferation of new blood vessels, accompanied by production of vascular-endothelial growth factor, appeared prominent during fibrosis regression months after curative treatment of schistosomiasis. Thus, angiogenesis in schistosomiasis seems to have a two-way mode of action, participating both in fibrogenesis and in fibrosis degradation. Morphological observations presented here are in keeping with the possibility that, in the first case, angiogenesis allows pericytes to come in great numbers to the site of lesions and be detached from capillary walls and transformed into myofibroblasts, which are important extra-cellular matrix forming cells. During post-curative fibrosis regression, actin-containing pericytes appeared at various foci of tissue remodelling, especially at sites of repair of vascular lesions. The molecular and cell factors involved in both situations seem to be important subjects in need of further investigations and the schistosomiasis model certainly will be of great avail in this regard.

Angiogenesis and experimental hepatic fibrosis.

Angiogenesis is a basic change occurring during repair by granulation tissue. This process seems to precede fibrosis formation in most types of chronic liver disease. To examine its presence and significance in different types of hepatic insults, this paper sought to identify the presence, evolution and peculiarities of angiogenesis in the most common experimental models of hepatic fibrosis. The characterization of cells, vessels and extracellular matrix and the identification of factors associated with endothelium (factor VIII RA), vascular basement membrane, other components of the vascular walls (actin, elastin) and the presence of the vascular-endothelial growth factor were investigated. The models examined included Capillaria hepatica septal fibrosis, whole pig serum injections, carbon tetrachloride administration, main bile duct ligation and Schistosoma mansoni infection. The first four models were performed in rats, while the last used mice. All models studied exhibited prominent angiogenesis. The most evident relationship between angiogenesis and fibrosis occurred with the C. hepatica model due to circumstances to be discussed. Special attention was paid to the presence of pericytes and to their tendency to become detached from the vascular wall and be transformed into myofibroblasts, which is a sequence of events that explains the decisive role angiogenesis plays in fibrosis.

Influence of laser photobiomodulation upon connective tissue remodeling during wound healing.

The modulation of collagen fibers during experimental skin wound healing was studied in 112 Wistar rats submitted to laser photobiomodulation treatment. A standardized 8mm-diameter wound was made on the dorsal skin of all animals. In half of them, 0.2ml of a silica suspension was injected along the border of the wound in order to enhance collagen deposition and facilitate observation. The others received saline as vehicle. The treatment was carried out by means of laser rays from an aluminum-gallium arsenide diode semiconductor with 9mW applied every other day (total dose=4J/cm2) on the borders of the wound. Tissue sections obtained from four experimental groups representing sham-irradiated animals, laser, silica and the association of both, were studied after 3, 7, 10, 15, 20, 30 and 60 days from the laser application. The wounded skin area was surgically removed and submitted to histological, immunohistochemical, ultrastructural, and immunofluorescent studies. Besides the degree and arrangement of collagen fibers and of their isotypes, the degree of edema, the presence of several cell types especially pericytes and myofibroblasts, were described and measured. The observation of Sirius-red stained slides under polarized microscopy revealed to be of great help during the morphological analysis of the collagen tissue dynamic changes. It was demonstrated that laser application was responsible for edema regression and a diminution in the number of inflammatory cells (p<0.05). An evident increase in the number of actin-positive cells was observed in the laser-treated wounds. Collagen deposition was less than expected in silica-treated wounds, and laser treatment contributed to its better differentiation and modulation in all irradiated groups. Thus, laser photobiomodulation was able to induce several modifications during the cutaneous healing process, especially in favoring newly-formed collagen fibers to be better organized and compactedly disposed.

Repeated infections with Schistosoma mansoni and liver fibrosis in undernourished mice.

The mouse model of schistosomal periportal fibrosis (Symmers' "pipestem" fibrosis), that develops in 30-50% of the infected animals, is not reproduced in undernourished mice. Host nutritional status is likely to be a variable that may influence the outcome and progression of infection, since it interferes with the dynamics of connective tissue changes occurring in chronic hepatic schistosomiasis. Re-infections increase the occurrence of periportal liver fibrosis in well-nourished animals, but it is not known how undernourished mice would behave being repeatedly re-infected. So, 21-day-old male albino Swiss mice were individually exposed to 30 cercariae (percutaneous route) of the BH strain of Schistosoma mansoni, 4 weeks after being on a low-protein diet. Control animals were fed on a commercial balanced chow for mice. The nutritional status was evaluated by body weight gain and measurement of food intake. Mice were divided into four groups: A1 (undernourished, single infected), A2 (well-nourished, single infected), B1 (undernourished, re-infected), B2 (well-nourished, re-infected). The primary infection was performed 4 weeks after ingesting the respective diet. Re-infections started 45 days later, with exposure to 15 cercariae, at 15 day intervals. Mice were sacrificed 18 weeks after the primary exposure. The livers were submitted to morphological (gross and microscopic pathology), morphometric (percentage of fibrosis; granuloma size; volume and numerical densities) by using semi-automatic morphometry, and biochemical (quantification of collagen as hydroxyproline) studies. Worm burdens and hepatic egg counting were also recorded. Values for body weight gains were always lower in undernourished mice, the effects of re-infection being minimal on this regard. Liver and spleen weights were higher in well-nourished mice (either single infected or re-infected) and mainly related to the type of ingested diet. A greater number of re-infected well-nourished mice developed periportal fibrosis, but undernourished re-infected animals did not reproduce this lesion. The percentage of fibrosis and hepatic collagen content were higher in well-nourished mice, but differences between single infected and re-infected groups were not statistically significant.

How variable are hydroxyproline determinations made in different samples of the same liver?

OBJECTIVES: The haphazard distribution of fibrous tissue can interfere with quantitative methods for evaluating hepatic fibrosis. Inter-sample variation may represent a crucial issue when hydroxyproline measurement is used to quantify fibrosis. A comparative study of the hydroxyproline levels in normal and fibrotic rats is herein reported. MATERIAL AND METHODS: Twelve normal and 20 Capillaria hepatica-infected Wistar rats were used. Two fragments of the liver (A and B) of each rat were taken from separate areas and hydroxyproline measurements were made. Calculated differences in hydroxyproline measurements between samples from the same liver were analyzed by BOOTSTRAP. RESULTS: Differences in normal rats varied from 0.026 to 1.85 micromol of HP/g, in ten rats, the difference was less than 0.50 micromol. In infected rats, it varied from 0.04 to 2.86 micromol HP/g. Differences higher than 0.69 micromol/g were significant for normal rats (p<0.05) and above 1.22 micromol/g (p<0.05) for fibrotic rats. CONCLUSIONS: Hydroxyproline ratio in a normal liver kept a fair degree of reproducibility. In the presence of hepatic fibrosis, the levels of hydroxyproline may vary significantly between samples from a single liver and may have limited value in quantifying the extent of fibrosis.

Characterization of the vascular changes in schistosomal portal (pipestem) fibrosis of mice.

Mice chronically infected with Schistosoma mansoni develop one of two anatomical forms of hepatic lesions: severe, periportal (pipestem) fibrosis or milder, isolated granulomas. The pathogenesis of periportal fibrosis is poorly understood. In this work we compared mice with either periportal fibrosis or isolated granulomas to identify specific markers of severe pathology. BALB/c or Swiss Webster mice were infected with 30 cercarie, once or six times, and liver biopsies were performed to classify the animals into two pathological groups 16 weeks later. Sixty percent of the animals sacrificed at 20 or 24 weeks had periportal fibrosis, 15-20% had isolated granulomas and the remainder had indeterminate pathology. There was no correlation between frequency of infections or egg burden (eggs/gliver) at 20 and 24 weeks post-infection and the development of periportal fibrosis. Livers with periportal fibrosis at 20 or 24 weeks of infection were characterized by larger areas of fibrotic tissue and greater vascularization compared to livers of mice with isolated granulomas. Plastic casts of the portal vein system showed marked changes in vascular structure in mice with periportal fibrosis, including collateral vessels sprouting from the main portal branches, amputation of the more delicate peripheral ramifications, and distortions of the medium and small branches. Vascular changes were not observed in mice with isolated granulomas. These results suggest that the interaction between schistosome eggs and portal vascular changes is of paramount importance in the development of pipestem fibrosis.

Significance and fate of septal fibrosis of the liver.

Septal fibrosis commonly occurs during chronic diseases of the liver. It is experimentally reproduced in a proportion of rats treated with pig-serum, and in 100% of rats infected with Capillaria hepatica. These models have only been used in relatively short-term studies. To contribute to the natural history and significance of hepatic septal fibrosis it is important to disclose its fate after prolonged observation, and following partial or total withdrawal of its inciting cause. Adult Wistar rats were sacrificed 3, 6, 9 and 12 months following inoculation of 800 embryonated eggs of C. hepatica. Besides routine histology, liver sections were submitted to immunohistochemical, immunofluorescence and ultrastructural techniques for the identification of cells and extracellular matrix components present in the fibrous septa. Septal blood vessels were studied after portal vein perfusion with India-ink, while the hepatic functional profile and levels of anti-C. hepatica antibodies were determined in collected sera. Results revealed that all parasites were already dead 2 months from inoculation, and the accumulated eggs in the liver lost their capacity to embryonate around the 4th-6th month, when progressive reduction in the number of cells and in the amount of collagen occurred in the septa. Septal fibrosis persisted throughout the time of experimentation (12 months). This fibrosis was seen as a supporting stroma for septal vessels that conducted portal blood directly to the sinusoids. Thus, persistence of fibrosis was probably related to its morphological and functional association with blood vessels.

Pathogenesis of septal fibrosis of the liver. (An experimental study with a new model.).

Septal fibrosis is an important, frequent, and non-specific type of fibrosis associated with chronic liver diseases, but its pathogenesis is still poorly understood. An interesting model of septal fibrosis occurs in rats infected with the nematode Capillaria hepatica. This model was used to investigate the pathogenesis, site of origin, structure, and cell-types of septal fibrosis. Forty young adult Wistar rats were inoculated with 800 embryonated eggs of C. hepatica. Daily liver samples were obtained from the 20th to the 39th day after inoculation to cover the critical period when septal fibrosis usually starts. Routine histology, electron microscopy, immunohistochemistry, and indirect immunofluorescence were applied to the study of liver sections. Septal blood vessels were demonstrated by India ink perfusion of the portal vein system. Prominent angiogenesis was observed to precede collagen deposition. Besides angiogenesis and mesenchymal-cell mobilization, septal fibrosis was seen to originate from portal spaces and to course through acinar zone I in between sinusoids, inducing no alterations in them, with no evident participation of stellate hepatic cells. Septal fibrosis appeared as an adaptative type of response of the liver to chronic injury, which resulted in a new structure that is normal to other species and creates accessory vessels that drain portal blood into hepatic sinusoids.

Morphological signs of cirrhosis regression. Experimental observations on carbon tetrachloride-induced liver cirrhosis of rats.

Regression of hepatic cirrhosis is a controversial issue. Recently, a list of histopathological features, observed in human material, was suggested as a hallmark of cirrhosis in the process of regression. An investigation for the presence of these morphologic features was performed at monthly intervals in rats with proved carbon tetrachloride (CCl4)-induced cirrhosis over a period of 9 months following discontinuation of treatment, using sequential liver biopsies. Within the first 4 months, features of the "hepatic repair complex" were identified, together with the enlargement of the hepatic nodules and thinning of the fibrous septa. Subsequent to the 4 months, the histological picture, composed of large and inconspicuous nodules and delimited by thin and frequently incomplete fibrous septa "incomplete septal cirrhosis", appeared to be stabilized. These fibrous septa, when injected with India ink from the portal trunk, presented blood vessels that were seen to drain directly into the sinusoids. These findings suggested that when the cause of cirrhosis is removed, the liver may adapt itself to a new and permanent structure, probably compatible with normal or near-normal function, which may render hepatic cirrhosis clinically, although not morphologically, reversible.

[Regression of hepatic fibrosis]. / Regressão da fibrose hepática.

Extensive and persistent hepatic fibrosis has for a long time been considered irreversible. However, recent studies on the behavior of hepatic fibrosis, especially those related to evolution and involution of advanced schistosomiasis in man, have challenged this concept, and nowadays it is becoming clear that any type of fibrosis is reversible, including that associated with hepatic cirrhosis. The problem consists in identifying and eliminating its cause. Although fibrosis in the liver has little functional significance by itself, its severity derives from associated vascular changes. However, new data on fibrosis regression indicate that disappearance of fibrosis is usually accompanied by remodeling of vascular changes. But, there are peculiarities related to the anatomic type of fibrosis and to its functional significance, which suggest that sometimes fibrosis may indeed be irreversible. These aspects, some of which in need of further studies, are presented and discussed herein.

Significance of bile-duct changes in schistosomiasis.

Lesions involving the intra-hepatic biliary ducts in schistosomiasis have been reported in the literature, both in mice and man, but there are no data concerning their quantitative, evolutionary or post curative chemotherapeutic aspects on record. In order to obtain such data an investigation on this subject was attempted. Mice infected with 50 Schistosoma mansoni cercariae were submitted to a liver biopsy at the 9th week post-infection, and treated with 400 mg/bw praziquantel immediately afterwards. Infected and non-infected controls were submitted to the same procedures. By 19 weeks from cercarial exposure all surviving animals were sacrificed. The biliary ducts were counted on histological sections and the results were expressed as biliary ducts/portal spaces. This quantitative evaluation was compared with that from normal controls and revealed hyperplasia as the main biliary duct change (p<0.007) in schistosomiasis. Hyperplastic changes underwent only mild partial and not statistically significant regression after specific chemotherapy (p>0.05). Infected and untreated animals presented ductal changes that did not differ from those of the treated group. Measurements of serum bilirubin (total and direct), and gamma-glutamyl-transpeptidase (gamma-GT) did not reveal significant differences when animals from the several groups were compared. Thus, bile ducts exhibit a proliferative response in relation to neighboring S. mansoni injury to portal areas, but although these lesions are histopathologically impressive, they lack a functional or prognostic significance.

Comparison of immune responses of Schistosoma mansoni-infected mice with distinct chronic forms of the disease.

BACKGROUND: Schistosoma mansoni-infected mice tend to present with either one of two different hepatic pathological patterns during chronic infection: periportal fibrosis (PF) with portal concentration of periovular granulomas and fibrosis or isolated granulomas (IG), with scattered periovular granulomas within the liver. These are models for the two clinical presentations of schistosomiasis, the severe hepatosplenic and the mild intestinal forms. In the present work, we examined the relationship between the development of these histopathological aspects and immunological markers in S. mansoni-infected mice. Although BALB/c mice with PF and IG had similar egg numbers in the liver, PF mice had higher liver collagen contents than mice with IG. Cultured spleen cells from mice with PF and IG had similar proliferation 20 and 40 weeks after S. mansoni infection upon stimulation with parasite egg antigen (SEA) or mitogen (Con A). Production of IL-4 upon SEA stimulation was higher in cell cultures from mice with PF, whereas IL-5 and IFN-gamma levels were not statistically different between PF and IG groups. Mice with IG had similar serum concentrations of total IgE and anti-SEA IgG1, IgG2a, IgG2b and IgG3 compared to sera from PF mice. Levels of IgG1 and IgG2a antibodies were the highest and the lowest detected, respectively. In conclusion, isogenic BALB/c mice infected with S. mansoni that develop periportal fibrosis or isolated granulomas have similar immunological patterns despite the two pathologic forms of schistosomal liver fibrosis.

[Schistosomiasis in Brazil after one century of research]. / A esquistossomose no Brasil após quase um século de pesquisas.

An attempt to evaluate the importance of scientific research on Schistosomiasis in Brazil, since 1908 until now, reveals the difficulties and uncertainties of such a task, when current criteria for measuring scientific impact are employed. However, with due respect to the contribution of international research, the data originated from Brazilian research on schistosomiasis, during almost a century, now appear sufficient for dealing with all our practical and scientific needs in this area.

Capillaria hepatica-induced hepatic fibrosis in rats: paradoxical effect of repeated infections.

Multiple exposures to parasitic agents are considered an important factor in the genesis of the most severe forms of the diseases they cause. Capillaria hepatica-induced septal fibrosis of the liver in rats usually runs without signs of portal hypertension or hepatic failure. After determining the hepatic profile of 15 animals during the course of a single infection, we submitted 20 rats to multiple Capillaria hepatica infections to determine whether repeated exposures would augment fibrosis production, transforming septal hepatic fibrosis into a true cirrhosis. Ten single-infection rats served as controls. A total of 5 exposures, with 45-day intervals, were made. Histological changes were followed by means of surgical liver biopsies, collected prior to infection and to each re-infection. Functional changes were minimal and transient. Although a slight recrudescence of fibrosis was observed after the first two re-infections and when the single-infected control group was re-infected at the end of the experiment, subsequent re-infections failed to increase the amount of fibrosis. On the contrary, there occurred quantitative and qualitative evidence of collagen degradation and suppression of parasite development. These paradoxical results are in keeping with the hypothesis that a complex immunological modulation participates in the mechanism of hepatic fibrosis induced by Capillaria hepatica infection in rats.

Behavior of Schistosoma mansoni-induced histopathological lesions in Biomphalaria glabrata submitted to ionizing radiation.

Present report demonstrates that repeated radiation of Schistosoma mansoni-infected Biomphalaria glabrata, totaling 15,000 rads, caused a sudden, albeit transient, suppression of cercarial shedding. Initially, sporocysts practically disappeared from the snail tissues. The more resistant developing cercariae presented nuclear clumping and vacuolation, before undergoing lysis. No host tissue reaction was evident at any time. Thirty-four days after the last irradiation, the snails resumed cercarial elimination. By that time numerous sporocysts and developing cercariae were detected, disseminated throughout snail tissues in a pattern similar to that of a highly malignant neoplasm, with no signs of host cellular reactions, which on the other hand were present in non-irradiated infected controls. The region of the ovo-testis was apparently destroyed after radiation, but returned to its normal appearance around 40 days after the last radiation. Ionizing radiation affected both host and parasite in S. mansoni-infected Biomphalaria glabrata, but the resulting impressive changes were soon reversed.

Production of septal fibrosis of the liver by means of foreign protein injections into rats.

Similarities and differences in antigenic humoral responses and electrophoretic patterns between Capillaria hepatica and pig-serum were investigated as a contribution to the understanding of hepatic fibrosis induced by the parenteral administration of foreign proteins. Only two out of 10 rats receiving repeated intraperitoneal injections of an extract of Capillaria hepatica-infected mouse liver presented septal hepatic fibrosis (20%). Under the same experimental conditions, 4 out of 9 rats (44.4%) developed septal fibrosis following whole pig-serum administration. Injections of normal mouse liver extracts did not result in hepatic fibrosis. Since a 100% septal fibrosis rate is observed in experimentally Capillaria hepatica-infected rats, it appeared that Capillaria hepatica products continuously released from inside the liver creates a much more effective fibrosis inducing mechanism than the parenteral administration of such factors. Thus, repeated peritoneal administration of a foreign protein to rats would not reveal the full fibrogenic potential it may have under natural conditions.

Chemotherapeutic effects on larval stages of Schistosoma mansoni during infection and re-infection of mice.

The sensitivity of the larval stages of Schistosoma mansoni to chemotherapy with praziquantel and oxamniquine was tested in mice during primary and secondary infections and after different intervals from cercarial exposure. Worm recovery by perfusion of the porto-mesenteric system, followed by counting and a morphometric study of the parasite, allowed the conclusion that the relative resistance of the larval stages of S. mansoni to schistosomicide drugs, demonstrated in primary infections, also persists when the host is already infected. This indicates that a therapeutic failure may result when an infected host is treated some time after being re-infected, because of the presence of migrating, drug-resistant, immature forms of the parasite.

Genetic population structure of cercariae from an urban foci of Schistosoma mansoni, Brazil.

Rapid urbanization in Brazil has meant that many persons from rural areas where Schistosoma mansoni is endemic have migrated to cities. Discovery of a focus of active transmission in the city of Salvador prompted a citywide survey for active and potential transmission sites. Cercariae shed from infected snails collected from four locations were used to determine how these samples were related and if they were representative of the parasite population infecting humans. Each cercarial collection was greatly differentiated from the others, and diversity was significantly lower when compared with eggs from natural human infections in one site. Egg samples collected 7 years apart in one neighborhood showed little differentiation (Jost's D = 0.01-0.03). Given the clonal nature of parasite reproduction in the snail host and the short-term acquisition of parasites, cercariae from collections at one time point are unlikely to be representative of the diversity in the human population.